MEDICARE: GRETCHEN JACOB OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	RO156	KY

General Provider Information

NPI Number	:	1871740621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRETCHEN JACOB OTR/L

Provider Business Mailing Address
First Line	:	2069 WILLIAMSBURG RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-3015
Country	:	US
Telephone Number	:	859-277-0506
Fax Number	:

Provider Business Practice Location Address
First Line	:	2069 WILLIAMSBURG RD
Second Line	:
City	:	LEXINGTON
State	:	KY
Zip	:	40504-3015
Country	:	US
Telephone Number	:	859-277-0506
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2008
Last Update Date	:	08/23/2008

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